Information about your procedure from The British Association of Urological Surgeons (BAUS)

This leaflet contains evidence-based information about your proposed urological procedure. We have consulted specialist surgeons during its preparation, so that it represents best practice in UK urology. You should use it in addition to any advice already given to you. To view the online version of this leaflet, type the text below into your web browser: http://www.baus.org.uk/_userfiles/pages/files/Patients/Leaflets/Urethrectomy.pdf

Key Points • This involves removing the male urethra (waterpipe) because of the risk of cancer (or future cancer development) • It is usually done through an incision in your perineum (behind your scrotum) • You will get some temporary bruising around the incision and along your penis • You may get some temporary discharge from the tip of your penis until everything heals

What does this procedure involve? Removing the whole of your urethra (waterpipe), from the tip of your penis to your prostate gland, through a small incision in your perineum (the skin beneath your scrotum).

Bladder cancer can sometimes re-appear in your urethra after cystectomy (removal of your bladder) and construction of an ileal conduit. Because you no longer pass urine through your urethra after your bladder has been removed, you will not get bleeding in your urine to warn us that your cancer may have recurred in your urethra. Although this is rare, we sometimes advise that it should be removed to prevent the problem presenting later.

Your surgeon and team will advise you if you need to have your urethra removed at the same time as your cystectomy. Sometimes, we can only

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appreciate the risk of recurrence in your urethra after your bladder has been removed and examined carefully. What are the alternatives? • Regular telescopic examination of your urethra – with biopsies of any abnormal areas • Radiotherapy – to prevent cancer developing or to kill any cancer already present • Conservative management – with no active treatment What happens on the day of the procedure? Your urologist (or a member of their team) will briefly review your history and medications, and will discuss the surgery again with you to confirm your consent.

An anaesthetist will see you to discuss the options of a general anaesthetic or spinal anaesthetic. The anaesthetist will also discuss pain relief after the procedure with you.

We may provide you with a pair of TED stockings to wear, and give you a heparin injection to thin your blood. These help to prevent blood clots from developing and passing into your lungs. Your medical team will decide whether you need to continue these after you go home. Details of the procedure • we normally carry out the procedure under a general anaesthetic although it can be done with you awake, under a spinal anaesthetic • the anaesthetist may also use a caudal, epidural or spinal anaesthetic to reduce any discomfort afterwards • we may give you an injection of antibiotics before the procedure, after you have been checked for any allergies • we make a small incision in your perineum (between your scrotum and the anus, pictured) and we carefully remove the whole length of your urethra, right to the tip of your penis • we do not remove the body or head of your penis

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• it is important to remove the whole urethra (pictured) from the level of the prostate, just below the arch of the pubic bone, to the urethral meatus (external urinary opening) • we sometimes leave a drain near the incision (or down the penis into the space where the urethra used to be); this helps to reduce swelling and bruising • we normally remove the drain the next day • you should expect to be in hospital for 1 or 2 days

We will encourage you to get up and about as soon as possible. This reduces the risk of blood clots in your legs and helps your bowel to start working again. You will sit out in a chair shortly after the procedure and be shown deep breathing/leg exercises. We will encourage you to start drinking and eating as soon as possible. Are there any after-effects? The possible after-effects and your risk of getting them are shown below. Some are self-limiting or reversible, but others are not. We have not listed very rare after-effects (occurring in less than 1 in 250 patients) individually. The impact of these after-effects can vary a lot from patient to patient; you should ask your surgeon’s advice about the risks and their impact on you as an individual:

After-effect Risk

Temporary bruising and swelling of your All patients penis & in the incision

Inability to get an erection (impotence) or Almost all to ejaculate (unless the erection nerves are patients preserved during bladder removal)

Infection in your wound or an abscess in Between 1 in 10 & your incision requiring surgical drainage 1 in 50 patients

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Anaesthetic or cardiovascular problems Between 1 in 10 & possibly requiring intensive care (including 1 in 50 patients chest infection, pulmonary embolus, stroke, (your anaesthetist deep vein thrombosis, heart attack and can estimate your death) individual risk)

Between 1 in 10 & Pain or discomfort in your wound 1 in 50 patients

Failure to achieve an overall cure of your Between 1 in 10 & cancer 1 in 50 patients

Need for blood transfusion or return to Between 1 in 50 & theatres for significant bleeding 1 in 250 patients

Rectal injury at the time of surgery Between 1 in 50 & requiring a temporary colostomy (bowel 1 in 250 patients opening on your abdomen)

What is my risk of a hospital-acquired infection? Your risk of getting an infection in hospital is between 4 & 6%; this includes getting MRSA or a Clostridium difficile bowel infection. This figure is higher if you are in a “high-risk” group of patients such as patients who have had: • long-term drainage tubes (e.g. catheters); • bladder removal; • long hospital stays; or • multiple hospital admissions. What can I expect when I get home? • you will be given advice about your recovery at home • you will be given a copy of your discharge summary and a copy will also be sent to your GP • any antibiotics or other tablets you may need will be arranged & dispensed from the hospital pharmacy • by the time you get home, you should be able to perform “daily living” activities such as making a cup of tea and preparing food • your stitches are dissolvable and do not need to be removed • if you get a fever, bruising or excessive discharge from the wound you should contact your GP immediately

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• a follow-up appointment will be made for you six to 12 weeks after your surgery General information about surgical procedures Before your procedure Please tell a member of the medical team if you have: • an implanted foreign body (stent, joint replacement, pacemaker, heart valve, blood vessel graft); • a regular prescription for a blood thinning agent (e.g. warfarin, aspirin, clopidogrel, rivaroxaban, dabigatran); • a present or previous MRSA infection; or • a high risk of variant-CJD (e.g. if you have had a corneal transplant, a neurosurgical dural transplant or human growth hormone treatment).

Questions you may wish to ask If you wish to learn more about what will happen, you can find a list of suggested questions called "Having An Operation" on the website of the Royal College of Surgeons of England. You may also wish to ask your surgeon for his/her personal results and experience with this procedure.

For several years, BAUS has collected data from urologists undertaking this surgery. You can view these data, by unit and by Consultant, in the Surgical Outcomes Audit section of the BAUS website.

Before you go home We will tell you how the procedure went and you should:

• make sure you understand what has been done; • ask the surgeon if everything went as planned; • let the staff know if you have any discomfort; • ask what you can (and cannot) do at home; • make sure you know what happens next; and • ask when you can return to normal activities.

We will give you advice about what to look out for when you get home. Your surgeon or nurse will also give you details of who to contact, and how to contact them, in the event of problems.

Smoking and surgery Ideally, we would prefer you to stop smoking before any procedure. Smoking can worsen some urological conditions and makes complications more likely after surgery. For advice on stopping, you can:

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• contact your GP; • access your local NHS Smoking Help Online; or • ring the free NHS Smoking Helpline on 0300 123 1044.

Driving after surgery It is your responsibility to make sure you are fit to drive after any surgical procedure. You only need to contact the DVLA if your ability to drive is likely to be affected for more than three months. If it is, you should check with your insurance company before driving again. What should I do with this information? Thank you for taking the trouble to read this information. Please let your urologist (or specialist nurse) know if you would like to have a copy for your own records. If you wish, the medical or nursing staff can also arrange to file a copy in your hospital notes. What sources have we used to prepare this leaflet? This leaflet uses information from consensus panels and other evidence- based sources including: • the Department of Health (England); • the Cochrane Collaboration; and • the National Institute for Health and Care Excellence (NICE).

It also follows style guidelines from: • the Royal National Institute for Blind People (RNIB); • the Patient Information Forum; and • the Plain English Campaign. Disclaimer We have made every effort to give accurate information but there may still be errors or omissions in this leaflet. BAUS cannot accept responsibility for any loss from action taken (or not taken) as a result of this information.

PLEASE NOTE The staff at BAUS are not medically trained, and are unable to answer questions about the information provided in this leaflet. If you do have any questions, you should contact your urologist, specialist nurse or GP.

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